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Barberio J, Lash TL, Nooka AK, Naimi AI, Patzer RE, Kim C. Real-World Risk of Severe Cytopenias in Multiple Myeloma Patients Sequentially Treated with Immunomodulatory Drugs. Acta Haematol 2024:000539127. [PMID: 38735288 DOI: 10.1159/000539127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Most multiple myeloma (MM) patients experience cytopenias, likely driven by both disease and treatment-related factors. Immunomodulatory agents (IMiDs), which form the backbone of most anti-myeloma regimens, are known to cause higher grade cytopenias. In this context, the impact of sequential IMiD treatments on cytopenia risk is unknown. METHODS We evaluated the cumulative risks of severe cytopenias following second line of therapy (LOT) initiation in 5573 MM patients in the Flatiron Health database. Patients for whom both LOTs 1 and 2 contained IMiDs were considered "sequentially exposed"; those for whom neither contained IMiDs were "never exposed." RESULTS For the neutropenia outcome, compared to the never exposed, the sequentially exposed had the highest 1-year risk (risk difference [RD] 12%), followed by those only recently exposed during LOT 2 (RD 8%), then by those with only past exposure during LOT 1 (RD 5%). A similar pattern was observed for leukopenia, but no meaningful differences were observed for anemia or thrombocytopenia. The associations between sequential exposure, versus never, with neutropenia and leukopenia were even stronger among those with a recent cytopenia history. CONCLUSION Results suggest that sequential exposure to IMiDs is a risk factor for higher grade cytopenias. These findings have profound clinical implications in choosing newer LOTs with potential risks of cytopenia.
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Drewry KM, Buford J, Patzer RE. Access to the Transplant Waiting List: All-too-Familiar Inequities Even Among Younger and Healthier Candidates. Am J Kidney Dis 2024; 83:684-687. [PMID: 38154783 DOI: 10.1053/j.ajkd.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Kelsey M Drewry
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Jade Buford
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rachel E Patzer
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana.
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Barberio J, Naimi AI, Patzer RE, Kim C, Hernandez RK, Brookhart MA, Gilbertson D, Bradbury BD, Lash TL. Influence of Incomplete Death Information on Cumulative Risk Estimates in United States Claims Data. Am J Epidemiol 2024:kwae034. [PMID: 38583932 DOI: 10.1093/aje/kwae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
Administrative claims databases often do not capture date or fact of death, so studies using these data may inappropriately treat death as a censoring event-equivalent to other withdrawal reasons-rather than a competing event. We examined 1-, 3-, and 5-year inverse-probability-of-treatment-weighted cumulative risks of a composite cardiovascular outcome among 34,527 initiators of telmisartan (exposure) and ramipril (referent) ages ≥55 in Optum claims from 2003 to 2020. Differences in cumulative risks of the cardiovascular endpoint due to censoring of death (cause-specific), as compared to treating death as a competing event (sub-distribution), increased with greater follow-up time and older age, where event and mortality risks were higher. Among ramipril users (selected results), 5-year cause-specific and sub-distribution cumulative risk estimates per 100, respectively, were 16.4 (95% CI 15.3, 17.5) and 16.2 (95% CI 15.1, 17.3) among ages 55-64 (difference=0.2) and were 43.2 (95% CI 41.3, 45.2) and 39.7 (95% CI 37.9, 41.4) among ages ≥75 (difference=3.6). Plasmode simulation results demonstrated the differences in cause-specific versus sub-distribution cumulative risks to increase with increasing mortality rate. We suggest researchers consider the cohort's baseline mortality risk when deciding whether real-world data with incomplete death information can be used without concern.
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Affiliation(s)
- Julie Barberio
- Department of Epidemiology, Emory University, Atlanta, GA and Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | - Ashley I Naimi
- Department of Epidemiology, Emory University, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory University, Atlanta, GA and Department of Surgery, Emory University, Atlanta, GA
| | - Christopher Kim
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | | | - M Alan Brookhart
- Target RWE/NoviSci, Inc, Chapel Hill, NC and Department of Population Health Sciences, Duke University, Durham, NC
| | | | - Brian D Bradbury
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA and Department of Epidemiology, University of California, Los Angeles, CA, USA
| | - Timothy L Lash
- Department of Epidemiology, Emory University, Atlanta, GA
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Wilk AS, Drewry KM, Escoffery C, Lea JP, Pastan SO, Patzer RE. Kidney Transplantation Contraindications: Variation in Nephrologist Practice and Training Vintage. Kidney Int Rep 2024; 9:888-897. [PMID: 38765582 PMCID: PMC11101805 DOI: 10.1016/j.ekir.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/08/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Health system leaders aim to increase access to kidney transplantation in part by encouraging nephrologists to refer more patients for transplant evaluation. Little is known about nephrologists' referral decisions and whether nephrologists with older training vintage weigh patient criteria differently (e.g., more restrictively). Methods Using a novel, iteratively validated survey of US-based nephrologists, we examined how nephrologists assess adult patients' suitability for transplant, focusing on established, important criteria: 7 clinical (e.g., overweight) and 7 psychosocial (e.g., insurance). We quantified variation in nephrologist restrictiveness-proportion of criteria interpreted as absolute or partial contraindications versus minor or negligible concerns-and tested associations between restrictiveness and nephrologist age (proxy for training vintage) in logistic regression models, controlling for nephrologist-level and practice-level factors. Results Of 144 nephrologists invited, 42 survey respondents (29% response rate) were 85% male and 54% non-Hispanic White, with mean age 52 years, and 67% spent ≥1 day/wk in outpatient dialysis facilities. Nephrologists interpreted patient criteria inconsistently; consistency was lower for psychosocial criteria (intraclass correlation coefficient: 0.28) than for clinical criteria (intraclass correlation coefficient: 0.43; P < 0.01). With each additional 10 years of age, nephrologists' odds of interpreting criteria restrictively (top tertile) doubled (adjusted odds ratio [aOR] 1.96; 95% confidence interval [CI]: 0.95-4.07), with marginal statistical significance. This relationship was significant when interpreting psychosocial criteria (aOR: 3.18; 95% CI: 1.16-8.71) but not when interpreting clinical criteria (aOR: 1.12; 95% CI: 0.52-2.38). Conclusion Nephrologists interpret evaluation criteria variably when assessing patient suitability for transplant. Guideline-based educational interventions could influence nephrologists' referral decision-making differentially by age.
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Affiliation(s)
- Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kelsey M. Drewry
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cam Escoffery
- Behavioral Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Janice P. Lea
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory University Transplant Center, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Harding JL, Di M, Pastan SO, Doucet N, Rossi A, DuBay D, Rice T, Patzer RE. Examination of sex/gender disparities across the continuum of kidney transplant steps. Nephrol Dial Transplant 2024; 39:717-719. [PMID: 37950570 PMCID: PMC11024813 DOI: 10.1093/ndt/gfad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Mengyu Di
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicole Doucet
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, GA, USA
| | - Derek DuBay
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Teresa Rice
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
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McDonnell JL, Urbanski MA, Drewry KM, Pastan SO, Lea JP, Arriola KJ, Escoffery C, Patzer RE, Wilk AS. Optimizing the Timing of Transplant Education: The Critical Role of Dialysis Care Professionals. Clin J Am Soc Nephrol 2024; 19:391-393. [PMID: 37902768 PMCID: PMC10937023 DOI: 10.2215/cjn.0000000000000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/24/2023] [Indexed: 10/31/2023]
Affiliation(s)
| | - Megan A. Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kelsey M. Drewry
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Janice P. Lea
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kimberly Jacob Arriola
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Adam S. Wilk
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
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Noreen SM, Patzer RE, Mohan S, Schold JD, Lyden GR, Miller J, Verbeke S, Stewart D, Fritz AR, McBride M, Snyder JJ. Augmenting the Unites States transplant registry with external mortality data: A moving target ripe for further improvement. Am J Transplant 2024; 24:190-212. [PMID: 37704059 DOI: 10.1016/j.ajt.2023.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/13/2023] [Accepted: 09/03/2023] [Indexed: 09/15/2023]
Abstract
The Organ Procurement and Transplantation Network conducts a robust death verification process when augmenting the United States transplant registry with external sources of data. Process enhancements added over 35,000 externally verified deaths across waitlist candidates and transplant recipients for all organs beginning in April 2022. Ninety-four percent of added posttransplant deaths occurred beyond 5 years posttransplant, and over 74% occurred beyond 10 years. Deceased donor solid organ recipients transplanted from January 1, 2010, through October 31, 2020, were analyzed from January and July 2022 Organ Procurement and Transplantation Network Standard Transplant Analysis and Research and the Scientific Registry of Transplant Recipients Standard Analysis Files to quantify the impact of including vs excluding unverified deaths (not releasable to researchers) on posttransplant patient survival estimates. Across all organs, 1- and 5-year posttransplant survival rates were not substantially impacted; meaningful differences were observed in 10-year survival among kidney recipients. These findings bear important implications for anyone who utilized transplant registry data to examine long-term outcomes prior to the updated verification process. Users of transplant surveillance data should interpret results of long-term outcomes cautiously, particularly differences across subpopulations, and the transplant community should identify ways to improve data quality and minimize the reporting burden on transplant institutions.
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Affiliation(s)
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA
| | - Grace R Lyden
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jonathan Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Scott Verbeke
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Amber R Fritz
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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Codner JA, Mlaver E, Solomon G, Saeed M, Di M, Shaffer VO, Dente CJ, Sweeney JF, Patzer RE, Sharma J. Improving Statewide Post-Operative Sepsis Performance Measurement Using Hospital Risk Adjustment Within a Surgical Collaborative. Surg Infect (Larchmt) 2024; 25:63-70. [PMID: 38157325 DOI: 10.1089/sur.2023.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Background: The Georgia Quality Improvement Program (GQIP) surgical collaborative participating hospitals have shown consistently poor performance in the post-operative sepsis category of National Surgical Quality Improvement Program data as compared with national benchmarks. We aimed to compare crude versus risk-adjusted post-operative sepsis rankings to determine high and low performers amongst GQIP hospitals. Patients and Methods: The cohort included intra-abdominal general surgery patients across 10 collaborative hospitals from 2015 to 2020. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) sepsis definition was used among all hospitals for case abstraction and NSQIP data were utilized to train and validate a multivariable risk-adjustment model with post-operative sepsis as the outcome. This model was used to rank GQIP hospitals by risk-adjusted post-operative sepsis rates. Rankings between crude and risk-adjusted post-operative sepsis rankings were compared ordinally and for changes in tertile. Results: The study included 20,314 patients with 595 cases of post-operative sepsis. Crude 30-day post-operative sepsis risk among hospitals ranged from 0.81 to 5.11. When applying the risk-adjustment model which included: age, American Society of Anesthesiology class, case complexity, pre-operative pneumonia/urinary tract infection/surgical site infection, admission status, and wound class, nine of 10 hospitals were re-ranked and four hospitals changed performance tertiles. Conclusions: Inter-collaborative risk-adjusted post-operative sepsis rankings are important to present. These metrics benchmark collaborating hospitals, which facilitates best practice exchange from high to low performers.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Eli Mlaver
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Gina Solomon
- Georgia Trauma Commission, Atlanta, Georgia, USA
| | - Muhammad Saeed
- Department of Surgery, Augusta University, Augusta, Georgia, USA
| | - Mengyu Di
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | - John F Sweeney
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Rachel E Patzer
- Department of Surgery, Emory University, Atlanta, Georgia, USA
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Urbanski M, Lee YTH, Escoffery C, Buford J, Plantinga L, Pastan SO, Hamoda R, Blythe E, Patzer RE. Implementation of the ASCENT Trial to Improve Transplant Waitlisting Access. Kidney Int Rep 2024; 9:225-238. [PMID: 38344743 PMCID: PMC10851002 DOI: 10.1016/j.ekir.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 04/28/2024] Open
Abstract
Introduction The Allocation System for changes in Equity in Kidney Transplantation (ASCENT) study was a hybrid type 1 trial of a multicomponent intervention among 655 US dialysis facilities with low kidney transplant waitlisting to educate staff and patients about kidney allocation system (KAS) changes and increase access to and reduce racial disparities in waitlisting. Intervention components included a staff webinar, patient and staff educational videos, and facility-specific feedback reports. Methods Implementation outcomes were assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework. Postimplementation surveys were administered among intervention group facilities (n = 334); interviews were conducted with facility staff (n = 6). High implementation was defined as using 3 to 4 intervention components, low implementation as using 1 to 2 components, and nonimplementation as using no components. Results A total of 331 (99%) facilities completed the survey; 57% were high implementers, 31% were low implementers, and 12% were nonimplementers. Waitlisting events were higher or similar among high versus low implementer facilities for incident and prevalent populations; for Black incident patients, the mean proportion waitlisted in low implementer facilities was 0.80% (95% confidence interval [CI]: 0.73-0.87) at baseline and 0.55% at 1-year (95% CI: 0.48-0.62) versus 0.83% (95% CI: 0.78-0.88) at baseline and 1.40% at 1-year (95% CI: 1.35-1.45) in high implementer facilities. Interviews revealed that the intervention helped facilities prioritize transplant education, but that intervention components were not uniformly shared. Conclusion The findings provide important context to interpret ASCENT effectiveness results and identified key barriers and facilitators to consider for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.
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Affiliation(s)
- Megan Urbanski
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
| | - Yi-Ting Hana Lee
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jade Buford
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Laura Plantinga
- University of California San Francisco, Department of Medicine, Divisions of Rheumatology and Nephology, San Francisco, California, USA
| | - Stephen O. Pastan
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Reem Hamoda
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emma Blythe
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana, USA
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Salame N, Sow YN, Siira MR, Garg A, Chen SC, Patzer RE, Kavalieratos D, Orenstein LAV. Factors Affecting Treatment Selection Among Patients With Hidradenitis Suppurativa. JAMA Dermatol 2024; 160:179-186. [PMID: 38198173 PMCID: PMC10782374 DOI: 10.1001/jamadermatol.2023.5425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/03/2023] [Indexed: 01/11/2024]
Abstract
Importance Despite the US Food and Drug Administration's approval of adalimumab for the treatment of hidradenitis suppurativa (HS), prescription rates remain low, indicating a critical gap between evidence-based guidelines and clinical practice. Understanding the medical decision-making process that these patients use when considering biologic agents and other HS therapies may uncover opportunities for improved patient-physician communication and HS disease control. Objective To elucidate factors that affect the medical decision-making process for patients with HS, with an emphasis on biologic therapies. Design, Setting, and Participants Open-ended semistructured interviews were conducted with English-speaking adults with HS (aged ≥18 years) recruited from 2 dermatology clinics that are part of Emory University School of Medicine in Atlanta, Georgia. All participants had an average 7-day pain score of 1 or higher on a 0- to 10-point numeric rating scale. Surveys were conducted between November 2019 and March 2020, and data were analyzed from December 2021 to August 2022. Data collection continued until thematic saturation was reached at 21 interviews. Results A total of 21 participants (median [IQR] age, 38.5 [27.9-43.4] years; 16 females [76%]) were included in the analysis. Almost all participants (96%) had Hurley stage II or III disease, and 15 (71%) had a history of adalimumab use. Suffering threshold, perceptions of treatment risk, treatment fatigue, disease understanding, and sources of information (included dermatologists, the internet, advertisements, and friends and loved ones) were identified as factors affecting participants' decisions to initiate new treatments for HS. Conclusions and Relevance Results of this qualitative study suggest that mitigating misconceptions about treatment risk, identifying gaps in disease knowledge, and emphasizing early treatment to prevent scarring and disease progression may empower patients with HS to engage in treatment planning and to try new therapies.
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Affiliation(s)
- Nicole Salame
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Meron R. Siira
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Suephy C. Chen
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
| | - Rachel E. Patzer
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
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Barberio J, Hernandez RK, Naimi AI, Patzer RE, Kim C, Lash TL. Characterizing Fit-for-Purpose Real-World Data: An Assessment of a Mother-Infant Linkage in the Japan Medical Data Center Claims Database. Clin Epidemiol 2024; 16:31-43. [PMID: 38313043 PMCID: PMC10838663 DOI: 10.2147/clep.s429246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/13/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose Observational postapproval safety studies are needed to inform medication safety during pregnancy. Real-world databases can be valuable for supporting such research, but fitness for regulatory purpose must first be vetted. Here, we demonstrate a fit-for-purpose assessment of the Japan Medical Data Center (JMDC) claims database for pregnancy safety regulatory decision-making. Patients and Methods The Duke-Margolis framework considers a database's fitness for regulatory purpose based on relevancy (capacity to answer the research question based on variable availability and a sufficiently sized, representative population) and quality (ability to validly answer the research question based on data completeness and accuracy). To assess these considerations, we examined descriptive characteristics of infants and pregnancies among females ages 12-55 years in the JMDC between January 2005 and March 2022. Results For relevancy, we determined that critical data fields (maternal medications, infant major congenital malformations, covariates) are available. Family identification codes permitted linkage of 385,295 total mother-infant pairs, 57% of which were continuously enrolled during pregnancy. The prevalence of specific congenital malformation subcategories and maternal medical conditions were representative of the general population, but preterm births were below expectations (3.6% versus 5.6%) in this population. For quality, our methods are expected to accurately identify the complete set of mothers and infants with a shared health insurance plan. However, validity of gestational age information was limited given the high proportion (60%) of missing live birth delivery codes coupled with suppression of infant birth dates and inaccessibility of disease codes with gestational week information. Conclusion The JMDC may be well suited for descriptive studies of pregnant people in Japan (eg, comorbidities, medication usage). More work is needed to identify a method to assign pregnancy onset and delivery dates so that in utero medication exposure windows can be defined more precisely as needed for many regulatory postapproval pregnancy safety studies.
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Affiliation(s)
- Julie Barberio
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Center for Observational Research, Amgen, Inc, Thousand Oaks, CA, USA
| | | | - Ashley I Naimi
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Rachel E Patzer
- Department of Epidemiology, Emory University, Atlanta, GA, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Christopher Kim
- Center for Observational Research, Amgen, Inc, Thousand Oaks, CA, USA
| | - Timothy L Lash
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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Montoya MM, Gander JC, Suglia SF, McDonald B, Patel SA, Davis T, Patzer RE, Jagannathan R, Teunis L, Harding JL. Racial Disparities in COVID-19 Severity Are Partially Mediated by Chronic Stress-Evidence from a Large Integrated Healthcare System. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01920-6. [PMID: 38294635 DOI: 10.1007/s40615-024-01920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Racial and ethnic minorities have experienced a disproportionate burden of severe COVID-19. Whether chronic stress, also disproportionately experienced by racial and ethnic minorities, explains this excess risk is unknown. METHODS We identified 9577 adults (≥ 18 years) diagnosed with COVID-19 from January 1, 2020, through September 30, 2021, enrolled in Kaiser Permanente Georgia (KPGA) with complete biomarker data. Self-reported race (Black or White) was defined from electronic medical records. Chronic stress, defined as allostatic load (AL), a composite score (scale 0-7) based on seven cardio-metabolic biomarkers, was categorized as below (low AL) or above (high AL) the median. Severe COVID-19 was defined as hospitalization or mortality within 30 days of COVID-19 diagnosis. The association between race, AL, and severe COVID-19 was assessed using multivariable Poisson regression. The mediating effect of AL was assessed using the Valeri and VanderWeele method. All results were expressed as risk ratios (RRs) with 95% confidence intervals. RESULTS Overall, Black (vs. White) KPGA members had an 18% excess risk of AL (RR: 1.18, 95%CI: 1.14-1.23) and a 24% excess risk of severe COVID-19 (RR: 1.24, 95%CI: 1.12, 1.37). AL explained 23% of the Black-White disparities in severe COVID-19. CONCLUSIONS In our study, chronic stress, characterized by AL, partially mediated Black-White disparities in severe COVID-19 outcomes.
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Affiliation(s)
- Miranda M Montoya
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Bennett McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Shivani A Patel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Teaniese Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | | | - Ram Jagannathan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Larissa Teunis
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Koukounas KG, Thorsness R, Patzer RE, Wilk AS, Drewry KM, Mehrotra R, Rivera-Hernandez M, Meyers DJ, Kim D, Trivedi AN. Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model. JAMA 2024; 331:124-131. [PMID: 38193961 PMCID: PMC10777251 DOI: 10.1001/jama.2023.23649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/22/2023] [Indexed: 01/10/2024]
Abstract
Importance The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.
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Affiliation(s)
- Kalli G. Koukounas
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | | | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kelsey M. Drewry
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - David J. Meyers
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Daeho Kim
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
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McPherson L, Plantinga LC, Howards PP, Kramer M, Pastan SO, Patzer RE. Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease. Lupus 2024; 33:48-57. [PMID: 38019182 PMCID: PMC10842868 DOI: 10.1177/09612033231219739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD. METHODS Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start. RESULTS Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months). CONCLUSIONS Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.
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Affiliation(s)
- Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Laura C. Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Penelope P. Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Regenstrief Institute, Indianapolis, IN
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Harding JL, Doucet N, Patel SA, Davis T, McDonald B, Goldberg B, Patzer RE, Walker-Williams D, Jagannathan R, Teunis L, Gander JC. The Association Between Black vs. White Race and 30-Day Hospitalization Among People Diagnosed with COVID-19 Within an Integrated Care Setting: a Cohort Study. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01894-x. [PMID: 38110800 DOI: 10.1007/s40615-023-01894-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Black Americans are more likely to experience hospitalization from COVID-19 compared with White Americans. Whether this excess risk differs by age, sex, obesity, or diabetes, key risk factors for COVID hospitalization, among an integrated population with uniform healthcare access, are less clear. METHODS We identified all adult members (≥ 18 years) of Kaiser Permanente Georgia (KPGA) diagnosed with COVID-19 between January 1, 2020, and September 30, 2021 (N = 24,564). We restricted the analysis to members of Black or White race identified from electronic medical records. Our primary outcome was first hospitalization within 30 days of COVID-19 diagnosis. To assess the association between race and 30-day hospitalization, we performed multivariable logistic regression adjusting for several member and neighborhood-level characteristics, and tested for interactions of race with age, sex, diabetes, and obesity. A regression-based decomposition method was then used to estimate how much of the observed race disparity in 30-day hospitalization could be explained by member and neighborhood-level factors. RESULTS Overall, 11.27% of Black KPGA members were hospitalized within 30 days of a COVID diagnosis, as compared with 9.44% of White KPGA members. Black (vs. White) KPGA members had a 34% (aOR: 1.32 [95% CI: 1.19-1.47]) higher odds of 30-day hospitalization following COVID-19 after accounting for clinical differences. The odds of 30-day hospitalization in Black vs. White KPGA members did not differ significantly by sex (men: 1.46 [1.25-1.70]; women: 1.24 [1.07-1.43]), by age (18-29 years: 1.33 [0. 841-2.10]; 30-49 years: 1.26 [1.02-1.56]; ≥ 50 years: 1.24 [1.10-1.41]); by diabetes status (with diabetes: 1.38 [1.16-1.66]; without diabetes: 1.26 [1.11-1.44]), or by obesity (with obesity: 1.31 [1.15-1.50]; without obesity: 1.28 [1.06-1.53]). Factors that, if Black and White KPGA members had the same level of exposure, would be most likely to reduce the Black-White disparity in 30-day hospitalization from COVID-19 were obesity, history of flu vaccine, and neighborhood-level income and social vulnerability. CONCLUSIONS Early in the pandemic, Black (vs. White) members of an integrated health system had higher odds of being hospitalized within 30 days of COVID-19 diagnosis and this excess risk was similar by sex, age, and comorbidities. Factors that explained the largest proportions of race-based disparities were obesity, receipt of flu vaccine, and neighborhood-level social determinants of health. These findings suggest that social determinants of health, or other unmeasured factors, may be drivers of racial disparities in COVID-19 outcomes.
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Affiliation(s)
- Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Nicole Doucet
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Shivani A Patel
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Teaniese Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Bennett McDonald
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Benjamin Goldberg
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | | | - Ram Jagannathan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Larissa Teunis
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
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16
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Drewry K, Cummings JR, Patzer RE, Wilk AS. Characteristics of Nephrologists Participating in Medicare's Comprehensive ESRD Care Initiative. Am J Kidney Dis 2023:S0272-6386(23)00943-5. [PMID: 38070589 DOI: 10.1053/j.ajkd.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 09/18/2023] [Accepted: 09/30/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Kelsey Drewry
- Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia; Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Janet R Cummings
- Department of Health Policy and Management, Rollins School of Public Health at Emory University, Atlanta, Georgia
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health at Emory University, Atlanta, Georgia; Department of General Internal Medicine, Emory University School of Medicine, Atlanta, Georgia; Regenstrief Institute, Indianapolis, Indiana
| | - Adam S Wilk
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Garg AX, Yohanna S, Naylor KL, McKenzie SQ, Mucsi I, Dixon SN, Luo B, Sontrop JM, Beaucage M, Belenko D, Coghlan C, Cooper R, Elliott L, Getchell L, Heale E, Ki V, Nesrallah G, Patzer RE, Presseau J, Reich M, Treleaven D, Wang C, Waterman AD, Zaltzman J, Blake PG. Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation: The EnAKT LKD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1366-1375. [PMID: 37922156 PMCID: PMC10696487 DOI: 10.1001/jamainternmed.2023.5802] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 11/05/2023]
Abstract
Importance Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant. Objectives To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant. Design, Setting, and Participants This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis). Interventions Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders. Main Outcomes and Measures The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor. Results The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15). Conclusions and Relevance This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort. Trial Registration ClinicalTrials.gov Identifier: NCT03329521.
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Affiliation(s)
- Amit X. Garg
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kyla L. Naylor
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Susan Q. McKenzie
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Istvan Mucsi
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie N. Dixon
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Bin Luo
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
| | - Jessica M. Sontrop
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mary Beaucage
- Patient Governance Circle, Indigenous Peoples Engagement and Research Council and Executive Committee, Can-Solve CKD, Vancouver, British Columbia, Canada
- Provincial Patient and Family Advisory Council, Ontario Renal Network, Toronto, Ontario, Canada
- Patient co-lead Theme 1–Improve a Culture of Donation, Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Dmitri Belenko
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Candice Coghlan
- Centre for Living Organ Donation, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Toronto, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Leah Getchell
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Can-SOLVE CKD Network, Vancouver BC, Canada
| | - Esti Heale
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gihad Nesrallah
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-Solve CKD), Patient Council, Vancouver, British Columbia, Canada
| | - Darin Treleaven
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Carol Wang
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Research Methods, Evidence and Uptake, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amy D. Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter G. Blake
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Harding JL, Di M, Pastan SO, Rossi A, DuBay D, Gompers A, Patzer RE. Sex/Gender-Based Disparities in Early Transplant Access by Attributed Cause of Kidney Disease-Evidence from a Multiregional Cohort in the Southeast United States. Kidney Int Rep 2023; 8:2580-2591. [PMID: 38106598 PMCID: PMC10719652 DOI: 10.1016/j.ekir.2023.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction We examined sex/gender disparities across the continuum of transplant care by attributed cause of end-stage kidney disease (ESKD). Methods All adults (18-79 years; N = 43,548) with new-onset ESKD in Georgia, North Carolina, or South Carolina between 2015 and 2019 were identified from the United States Renal Data System (USRDS). Individuals were linked to the Early Steps to Transplant Access Registry (E-STAR) to obtain data on referral and evaluation. Waitlisting data was ascertained from USRDS. Using a Cox-proportional hazards model, with follow-up through 2020, we assessed the association between sex/gender and referral within 12 months (among all incident dialysis patients), evaluation start within 6 months (among referred patients), and waitlisting (among all evaluated patients) by attributed cause of ESKD (type 1 diabetes mellitus, type 2 diabetes mellitus, hypertension, glomerulonephritis, cystic disease, and other). Results Overall, women (vs. men) with type 2 diabetes-attributed ESKD were 13% (crude hazard ratio [HR]: 0.87 [0.83-0.91]), 14% (crude HR: 0.86 [0.81-0.91]), and 14% (crude HR: 0.86 [0.78-0.94]) less likely to be referred, evaluated, and waitlisted, respectively. Women (vs. men) with hypertension-attributed ESKD were 14% (crude HR: 0.86 [0.82-0.90]) and 8% (crude HR: 0.92 [0.87-0.98]) less likely to be referred and evaluated, respectively, but similarly likely to be waitlisted once evaluated (crude HR: 1.06 [0.97-1.15]). For all other attributed causes of ESKD, there was no sex/gender disparity in referral, evaluation, or waitlisting rates. Conclusion In the Southeast United States, sex/gender disparities in early access to kidney transplantation are specific to people with ESKD attributed to type 2 diabetes and hypertension.
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Affiliation(s)
- Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mengyu Di
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Derek DuBay
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Annika Gompers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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19
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Bhavsar NA, Patzer RE, Taber DJ, Ross-Driscoll K, Deierhoi Reed R, Caicedo-Ramirez JC, Gordon EJ, Matsouaka RA, Rogers U, Webster W, Adams A, Kirk AD, McElroy LM. Defining the Need for Causal Inference to Understand the Impact of Social Determinants of Health: A Primer on Behalf of the Consortium for the Holistic Assessment of Risk in Transplantation (CHART). Ann Surg Open 2023; 4:e337. [PMID: 38144885 PMCID: PMC10735082 DOI: 10.1097/as9.0000000000000337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/11/2023] [Indexed: 12/26/2023] Open
Abstract
Objective This study aims to introduce key concepts and methods that inform the design of studies that seek to quantify the causal effect of social determinants of health (SDOH) on access to and outcomes following organ transplant. Background The causal pathways between SDOH and transplant outcomes are poorly understood. This is partially due to the unstandardized and incomplete capture of the complex interactions between patients, their neighborhood environments, the tertiary care system, and structural factors that impact access and outcomes. Designing studies to quantify the causal impact of these factors on transplant access and outcomes requires an understanding of the fundamental concepts of causal inference. Methods We present an overview of fundamental concepts in causal inference, including the potential outcomes framework and direct acyclic graphs. We discuss how to conceptualize SDOH in a causal framework and provide applied examples to illustrate how bias is introduced. Results There is a need for direct measures of SDOH, increased measurement of latent and mediating variables, and multi-level frameworks for research that examine health inequities across multiple health systems to generalize results. We illustrate that biases can arise due to socioeconomic status, race/ethnicity, and incongruencies in language between the patient and clinician. Conclusions Progress towards an equitable transplant system requires establishing causal pathways between psychosocial risk factors, access, and outcomes. This is predicated on accurate and precise quantification of social risk, best facilitated by improved organization of health system data and multicenter efforts to collect and learn from it in ways relevant to specialties and service lines.
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Affiliation(s)
- Nrupen A. Bhavsar
- From the Department of Medicine, Duke University School of Medicine, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David J. Taber
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | | | | | | | - Elisa J. Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Roland A. Matsouaka
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Ursula Rogers
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Wendy Webster
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Andrew Adams
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Allan D. Kirk
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, NC
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McPherson LJ, Di M, Adams AA, Plantinga L, Pastan SO, Patzer RE. Geographic Differences in Racial Disparities in Access to Kidney Transplantation. Kidney Int Rep 2023; 8:2474-2477. [PMID: 38025234 PMCID: PMC10658202 DOI: 10.1016/j.ekir.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/17/2023] [Accepted: 08/02/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Laura J. McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mengyu Di
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Ayrenne A. Adams
- Department of Medicine, Division of General Internal Medicine and Innovation, New York University Grossman School of Medicine, New York, New York, USA
| | - Laura Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Yu M, King KL, Husain SA, Huml AM, Patzer RE, Schold JD, Mohan S. Discrepant Outcomes between National Kidney Transplant Data Registries in the United States. J Am Soc Nephrol 2023; 34:1863-1874. [PMID: 37535362 PMCID: PMC10631598 DOI: 10.1681/asn.0000000000000194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Effects of reduced access to external data by transplant registries to improve accuracy and completeness of the collected data are compounded by different data management processes at three US organizations that maintain kidney transplant-related datasets. This analysis suggests that the datasets have large differences in reported outcomes that vary across different subsets of patients. These differences, along with recent disclosure of previously missing outcomes data, raise important questions about completeness of the outcome measures. Differences in recorded deaths seem to be increasing in recent years, reflecting the adverse effects of restricted access to external data sources. Although these registries are invaluable sources for the transplant community, discrepancies and incomplete reporting risk undermining their value for future analyses, particularly when used for developing national transplant policy or regulatory measures. BACKGROUND Central to a transplant registry's quality are accuracy and completeness of the clinical information being captured, especially for important outcomes, such as graft failure or death. Effects of more limited access to external sources of death data for transplant registries are compounded by different data management processes at the United Network for Organ Sharing (UNOS), the Scientific Registry of Transplant Recipients (SRTR), and the United States Renal Data System (USRDS). METHODS This cross-sectional registry study examined differences in reported deaths among kidney transplant candidates and recipients of kidneys from deceased and living donors in 2000 through 2019 in three transplant datasets on the basis of data current as of 2020. We assessed annual death rates and survival estimates to visualize trends in reported deaths between sources. RESULTS The UNOS dataset included 77,605 deaths among 315,346 recipients and 61,249 deaths among 275,000 nonpreemptively waitlisted candidates who were never transplanted. The SRTR dataset included 87,149 deaths among 315,152 recipients and 60,042 deaths among 259,584 waitlisted candidates. The USRDS dataset included 89,515 deaths among 311,955 candidates and 63,577 deaths among 238,167 waitlisted candidates. Annual death rates among the prevalent transplant population show accumulating differences across datasets-2.31%, 4.00%, and 4.03% by 2019 from UNOS, SRTR, and USRDS, respectively. Long-term survival outcomes were similar among nonpreemptively waitlisted candidates but showed more than 10% discordance between USRDS and UNOS among transplanted patients. CONCLUSIONS Large differences in reported patient outcomes across datasets seem to be increasing, raising questions about their completeness. Understanding the differences between these datasets is essential for accurate, reliable interpretation of analyses that use these data for policy development, regulatory oversight, and research. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_24_JASN0000000000000194.mp3.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Rachel E. Patzer
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
- Department of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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22
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Sow Y, Salame N, Siira MR, Flowers N, Garg A, Patzer RE, Kavalieratos D, Curseen KA, Chen S, Orenstein LAV. Healthcare experiences among patients with hidradenitis suppurativa: a qualitative study. Br J Dermatol 2023; 189:624-626. [PMID: 37399246 PMCID: PMC10599793 DOI: 10.1093/bjd/ljad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/20/2023] [Accepted: 08/05/2023] [Indexed: 07/05/2023]
Abstract
In this qualitative study, 21 adults living with hidradenitis suppurativa (HS) were interviewed about their healthcare experiences. Participants detailed how delay in diagnosis, lack of provider knowledge, inadequate pain management, poor access to care and stigmatization negatively affected their interactions with the healthcare system. Improving disease knowledge among providers, proactively addressing HS-related pain and coordinating access to multidisciplinary care may improve healthcare experiences among individuals living with HS.
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Affiliation(s)
- Yacine Sow
- Morehouse School of Medicine, Atlanta, GA
| | | | | | | | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | | | | | - Kimberly A Curseen
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Suephy C Chen
- Department of Dermatology, Duke University School of Medicine, Durham, NC, USA
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23
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Buford J, Retzloff S, Wilk AS, McPherson L, Harding JL, Pastan SO, Patzer RE. Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States. Kidney Med 2023; 5:100706. [PMID: 37753250 PMCID: PMC10518364 DOI: 10.1016/j.xkme.2023.100706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown. Study Design Retrospective cohort study. Setting & Participants 439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020. Exposures Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years). Outcomes Placement on the United Network for Organ Sharing deceased donor waitlist. Analytical Approach Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age. Results Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02). Limitations Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients. Conclusions Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure. Plain-Language Summary Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.
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Affiliation(s)
- Jade Buford
- Regenstrief Institute, Indianapolis, Indiana
| | - Samantha Retzloff
- HIV Surveillance Branch (HSB), Division of HIV Prevention (DHP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Emory University School of Medicine, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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24
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Mohiuddin TA, Raol N, Tey CS, Horný M, Zhang C, Sharp WG, Chanani N, Patzer RE. Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery. J Pediatr 2023; 261:113593. [PMID: 37399917 DOI: 10.1016/j.jpeds.2023.113593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/27/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.
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Affiliation(s)
- Tahmina A Mohiuddin
- Medical Scholars Program, Augusta University/University of Georgia Medical Partnership, Athens, GA
| | - Nikhila Raol
- Department of Otolaryngology, Emory School of Medicine, Atlanta, GA; Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Ching S Tey
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Atlanta, GA; Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Chao Zhang
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - William G Sharp
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Children's Feeding Program, Children's Healthcare of Atlanta, Atlanta, GA
| | - Nikhil Chanani
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Sibley Heart Center, Alpharetta, GA; Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
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Ross-Driscoll K, Gunasti J, Ayuk-Arrey AT, Adler JT, Axelrod D, McElroy L, Patzer RE, Lynch R. Identifying and understanding variation in population-based access to liver transplantation in the United States. Am J Transplant 2023; 23:1401-1410. [PMID: 37302576 PMCID: PMC10529375 DOI: 10.1016/j.ajt.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/04/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
We aimed to identify variations in liver transplant access across transplant referral regions (TRRs), accounting for differences in population characteristics and practice environments. Adult end-stage liver disease (ESLD) deaths and liver waitlist additions from 2015 to 2019 were included. The primary outcome was listing-to-death ratio (LDR). We modeled the LDR as a continuous variable and obtained adjusted LDR estimates for each TRR, accounting for clinical and demographic characteristics of ESLD decedents, socioeconomic and health care environment within the TRR, and characteristics of the transplant environment. The overall mean LDR was 0.24 (range: 0.10-0.53). In the final model, proportion of patients living in poverty and concentrated poverty was negatively associated with LDR; organ donation rate was positively associated with LDR. The R2 was 0.60, indicating that 60% of the variability in LDR was explained by the model. Approximately 40% of this variation remained unexplained and may be due to transplant center behaviors amenable to intervention to improve access to care for patients with ESLD.
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Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Jonathan Gunasti
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arrey-Takor Ayuk-Arrey
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joel T Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lisa McElroy
- Division of Abdominal Transplantation, Department of Surgery and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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26
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Cron DC, Tsai TC, Patzer RE, Husain SA, Xiang L, Adler JT. The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation. JAMA Netw Open 2023; 6:e2322803. [PMID: 37432684 PMCID: PMC10336615 DOI: 10.1001/jamanetworkopen.2023.22803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/25/2023] [Indexed: 07/12/2023] Open
Abstract
Importance Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. Objective To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. Design, Setting, and Participants This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Exposure Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. Main Outcomes and Measures The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. Results A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). Conclusions and Relevance In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.
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Affiliation(s)
- David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas C. Tsai
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel T. Adler
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
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Horwitz LI, Thaweethai T, Brosnahan SB, Cicek MS, Fitzgerald ML, Goldman JD, Hess R, Hodder SL, Jacoby VL, Jordan MR, Krishnan JA, Laiyemo AO, Metz TD, Nichols L, Patzer RE, Sekar A, Singer NG, Stiles LE, Taylor BS, Ahmed S, Algren HA, Anglin K, Aponte-Soto L, Ashktorab H, Bassett IV, Bedi B, Bhadelia N, Bime C, Bind MAC, Black LJ, Blomkalns AL, Brim H, Castro M, Chan J, Charney AW, Chen BK, Chen LQ, Chen P, Chestek D, Chibnik LB, Chow DC, Chu HY, Clifton RG, Collins S, Costantine MM, Cribbs SK, Deeks SG, Dickinson JD, Donohue SE, Durstenfeld MS, Emery IF, Erlandson KM, Facelli JC, Farah-Abraham R, Finn AV, Fischer MS, Flaherman VJ, Fleurimont J, Fonseca V, Gallagher EJ, Gander JC, Gennaro ML, Gibson KS, Go M, Goodman SN, Granger JP, Greenway FL, Hafner JW, Han JE, Harkins MS, Hauser KSP, Heath JR, Hernandez CR, Ho O, Hoffman MK, Hoover SE, Horowitz CR, Hsu H, Hsue PY, Hughes BL, Jagannathan P, James JA, John J, Jolley S, Judd SE, Juskowich JJ, Kanjilal DG, Karlson EW, Katz SD, Kelly JD, Kelly SW, Kim AY, Kirwan JP, Knox KS, Kumar A, Lamendola-Essel MF, Lanca M, Lee-lannotti JK, Lefebvre RC, Levy BD, Lin JY, Logarbo BP, Logue JK, Longo MT, Luciano CA, Lutrick K, Malakooti SK, Mallett G, Maranga G, Marathe JG, Marconi VC, Marshall GD, Martin CF, Martin JN, May HT, McComsey GA, McDonald D, Mendez-Figueroa H, Miele L, Mittleman MA, Mohandas S, Mouchati C, Mullington JM, Nadkarni GN, Nahin ER, Neuman RB, Newman LT, Nguyen A, Nikolich JZ, Ofotokun I, Ogbogu PU, Palatnik A, Palomares KTS, Parimon T, Parry S, Parthasarathy S, Patterson TF, Pearman A, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Porterfield JZ, Quigley JG, Quinn DK, Raissy H, Rebello CJ, Reddy UM, Reece R, Reeder HT, Rischard FP, Rosas JM, Rosen CJ, Rouphael NG, Rouse DJ, Ruff AM, Saint Jean C, Sandoval GJ, Santana JL, Schlater SM, Sciurba FC, Selvaggi C, Seshadri S, Sesso HD, Shah DP, Shemesh E, Sherif ZA, Shinnick DJ, Simhan HN, Singh U, Sowles A, Subbian V, Sun J, Suthar MS, Teunis LJ, Thorp JM, Ticotsky A, Tita ATN, Tragus R, Tuttle KR, Urdaneta AE, Utz PJ, VanWagoner TM, Vasey A, Vernon SD, Vidal C, Walker T, Ward HD, Warren DE, Weeks RM, Weiner SJ, Weyer JC, Wheeler JL, Whiteheart SW, Wiley Z, Williams NJ, Wisnivesky JP, Wood JC, Yee LM, Young NM, Zisis SN, Foulkes AS. Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design. PLoS One 2023; 18:e0286297. [PMID: 37352211 PMCID: PMC10289397 DOI: 10.1371/journal.pone.0286297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023] Open
Abstract
IMPORTANCE SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. METHODS RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. DISCUSSION RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options. REGISTRATION NCT05172024.
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Affiliation(s)
- Leora I. Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tanayott Thaweethai
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Shari B. Brosnahan
- Division of Pulmonary Critical Care and Sleep Medicine, NYU Langone Health, New York, New York, United States of America
| | - Mine S. Cicek
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Megan L. Fitzgerald
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Jason D. Goldman
- Division of Infectious Diseases, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Rachel Hess
- Department of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - S. L. Hodder
- Department of Medicine, West Virginia University, Morgantown, West Virginia, United States of America
| | - Vanessa L. Jacoby
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Michael R. Jordan
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Medford, Massachusetts, United States of America
| | - Jerry A. Krishnan
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Adeyinka O. Laiyemo
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Torri D. Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Lauren Nichols
- Body Politic COVID-19 Support Group, Boston, Massachusetts, United States of America
| | - Rachel E. Patzer
- Department of Medicine and Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Anisha Sekar
- Patient Led Research Collaboration on COVID-19, Washington, DC, United States of America
| | - Nora G. Singer
- Department of Medicine and Rheumatology, The MetroHealth Medical Center, Cleveland, Ohio, United States of America
| | - Lauren E. Stiles
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, United States of America
| | - Barbara S. Taylor
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Shifa Ahmed
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Heather A. Algren
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Khamal Anglin
- Department of Epidemiology and Biostatistics, University of California at San Francisco Institute of Global Health Sciences, San Francisco, San Francisco, California, United States of America
| | - Lisa Aponte-Soto
- College of Science and Health, Department of Health Sciences, DePaul University, Chicago, Illinois, United States of America
| | - Hassan Ashktorab
- Department of Medicine, Howard University, Washington, DC, United States of America
| | - Ingrid V. Bassett
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brahmchetna Bedi
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Nahid Bhadelia
- Center for Emerging Infectious Diseases Policy and Research, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Christian Bime
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Marie-Abele C. Bind
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lora J. Black
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Andra L. Blomkalns
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - Hassan Brim
- Department of Pathology, Howard University, Washington, DC, United States of America
| | - Mario Castro
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Alexander W. Charney
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Benjamin K. Chen
- Division of Infectious Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Li Qing Chen
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - David Chestek
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Lori B. Chibnik
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Dominic C. Chow
- Department of Medicine, University of Hawaii at Manoa John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Helen Y. Chu
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Rebecca G. Clifton
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Shelby Collins
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, The Ohio State University Hospital, Columbus, Ohio, United States of America
| | - Sushma K. Cribbs
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - John D. Dickinson
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Sarah E. Donohue
- Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Matthew S. Durstenfeld
- Department of Medicine, Division of Cardiology at Zuckerberg San Francisco General, University of California San Francisco, San Francisco, California, United States of America
| | - Ivette F. Emery
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Kristine M. Erlandson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
| | - Julio C. Facelli
- Department of Biomedical Informatics and Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, United States of America
| | - Rachael Farah-Abraham
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Aloke V. Finn
- Department of Pathology, CVPath Institute, Gaithersburg, Maryland, United States of America
| | - Melinda S. Fischer
- Department of Medicine, Division of Infectious Diseases and Infectious Diseases, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Valerie J. Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Judes Fleurimont
- Mile Square Health Center, University of Illinois Chicago, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Vivian Fonseca
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Emily J. Gallagher
- Department of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Maria Laura Gennaro
- Public Health Research Institute and Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Kelly S. Gibson
- Department of Obstetrics and Gynecology, MetroHealth System, Cleveland, Ohio, United States of America
| | - Minjoung Go
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Steven N. Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Frank L. Greenway
- Clinical Trials, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - John W. Hafner
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, Illinois, United States of America
| | - Jenny E. Han
- Department of Pulmonary and Critical Care, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Michelle S. Harkins
- Department of Internal Medicine University of New Mexico, Health Science Center, Albuquerque, New Mexico, United States of America
| | - Kristine S. P. Hauser
- Clinical Research Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - James R. Heath
- Department of Bioengineering, Institute for Systems Biology, Seattle, Washington, United States of America
| | - Carla R. Hernandez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - On Ho
- Seattle Children’s Therapeutics, Seattle, Washington, United States of America
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware, United States of America
| | - Susan E. Hoover
- Department of Clinical Research, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Harvey Hsu
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Priscilla Y. Hsue
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Judith A. James
- Department of Arthritis & Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, United States of America
| | - Janice John
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Sarah Jolley
- Department of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - S. E. Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Joy J. Juskowich
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Diane G. Kanjilal
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Elizabeth W. Karlson
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stuart D. Katz
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - J. Daniel Kelly
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Sara W. Kelly
- Department of Pediatrics & Department of Research Services, University of Illinois College of Medicine, Peoria, Illinois, United States of America
| | - Arthur Y. Kim
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John P. Kirwan
- Department Integrated Physiology and Molecular Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Kenneth S. Knox
- Department of Internal Medicine, University of Arizona, Phoenix, Arizona, United States of America
| | - Andre Kumar
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | | | - Margaret Lanca
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joyce K. Lee-lannotti
- Department of Internal Medicine and Neurology, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, United States of America
| | - R. Craig Lefebvre
- Communications Practice Area, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Bruce D. Levy
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Janet Y. Lin
- Department of Emergency Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Brian P. Logarbo
- Tulane Center for Clinical Research, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Jennifer K. Logue
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michele T. Longo
- Tulane Center for Clinical Neurosciences, Tulane School of Medicine, New Orleans, Louisiana, United States of America
| | - Carlos A. Luciano
- Department of Neurology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, United States of America
| | - Karen Lutrick
- Department of Family & Community Medicine, University of Arizona, College of Medicine – Tucson, Tucson, Arizona, United States of America
| | - Shahdi K. Malakooti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Gabrielle Maranga
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Jai G. Marathe
- Department of Medicine, Section of Infectious Diseases, Boston University Medical Center, Boston, Massachusetts, United States of America
| | - Vincent C. Marconi
- Department of Medicine, Infectious Diseases and Department of Global Health, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Gailen D. Marshall
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Christopher F. Martin
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Heidi T. May
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah, United States of America
| | - Grace A. McComsey
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Dylan McDonald
- Department of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Lucio Miele
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sindhu Mohandas
- Department of Infectious Diseases, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California, United States of America
| | - Christian Mouchati
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Janet M. Mullington
- Department of Neurology and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Girish N. Nadkarni
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Erica R. Nahin
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Robert B. Neuman
- Division of Cardiology, Kaiser Permanente of Georgia, Atlanta, Georgia, United States of America
| | - Lisa T. Newman
- Department of Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Amber Nguyen
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Janko Z. Nikolich
- Department of Immunobiology, University of Arizona College of Medicine, Tucson, Arizona, United States of America
| | - Igho Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Princess U. Ogbogu
- Division of Pediatric Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, United States of America
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Kristy T. S. Palomares
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey, United States of America
| | - Tanyalak Parimon
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sairam Parthasarathy
- Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Thomas F. Patterson
- Department of Medicine, Department of Infectious Disease, University of Texas Health, San Antonio, Texas, United States of America
| | - Ann Pearman
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Michael J. Peluso
- Division of HIV, Infectious Disease, and Global Medicine, University of California, San Francisco, California, United States of America
| | - Priscilla Pemu
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Christian M. Pettker
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Beth A. Plunkett
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois, United States of America
| | - Kristen Pogreba-Brown
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, United States of America
| | - Athena Poppas
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - J. Zachary Porterfield
- Department of Internal Medicine, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, United States of America
| | - John G. Quigley
- Department of Medicine, Division of Hematology/Oncology, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Hengameh Raissy
- Department of Pediatrics, University of New Mexico, Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Candida J. Rebello
- Department of Nutrition and Chronic Disease, Pennington Biomedical Research Center, Baton Rouge, Louisiana, United States of America
| | - Uma M. Reddy
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, United States of America
| | - Rebecca Reece
- Department of Medicine, Division of Infectious Diseases, West Virginia School of Medicine, Morgantown, West Virginia, United States of America
| | - Harrison T. Reeder
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Franz P. Rischard
- Department of Pulmonary and Critical Care, University of Arizona, Tucson, Arizona, United States of America
| | - Johana M. Rosas
- Department of Medicine, NYU Langone Health, New York, New York, United States of America
| | - Clifford J. Rosen
- MaineHealth Institute for Research, MaineHealth, Scarborough, Maine, United States of America
| | - Nadine G. Rouphael
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island, United States of America
| | - Adam M. Ruff
- Division of Pulmonary and Critical Care, University of Kansas Medical Center, Kansas City, Kansas City, United States of America
| | - Christina Saint Jean
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Grecio J. Sandoval
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jorge L. Santana
- Department of Medicine, University of Puerto Rico, San Juan, Puerto Rico, United States of America
| | - Shannon M. Schlater
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Frank C. Sciurba
- Department of Medicine, Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Caitlin Selvaggi
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sudha Seshadri
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center San Antonio, San Antonio, Texas, United States of America
| | - Howard D. Sesso
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Dimpy P. Shah
- Department of Population Health Sciences, Mays Cancer Center, University of Texas Health, San Antonio, Texas, United States of America
| | - Eyal Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Zaki A. Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of Medicine, Washington, DC, United States of America
| | - Daniel J. Shinnick
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Upinder Singh
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Amber Sowles
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, United States of America
| | - Vignesh Subbian
- Department of Biomedical Engineering, Department of Systems and Industrial Engineering, University of Arizona College of Engineering, Tucson, Arizona, United States of America
| | - Jun Sun
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Mehul S. Suthar
- Department of Pediatrics, Emory Vaccine Center, Emory University, Atlanta, Georgia, United States of America
| | - Larissa J. Teunis
- Health Services Research Center, Emory University, Atlanta, Georgia, United States of America
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Amberly Ticotsky
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology and Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Robin Tragus
- Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, United States of America
| | - Katherine R. Tuttle
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Alfredo E. Urdaneta
- Department of Emergency Medicine, Stanford University, Stanford, California, United States of America
| | - P. J. Utz
- Department of Internal Medicine, Stanford University, Stanford, California, United States of America
| | - Timothy M. VanWagoner
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Andrew Vasey
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Suzanne D. Vernon
- Department of Research, Bateman Horne Center, Salt Lake City, Utah, United States of America
| | - Crystal Vidal
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Tiffany Walker
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Honorine D. Ward
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - David E. Warren
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Ryan M. Weeks
- Department of Microbiology, Immunology, and Molecular Genetics, University of Kentucky, Lexington, Kentucky, United States of America
| | - Steven J. Weiner
- Department of Biostatistics, George Washington University, Washington, DC, United States of America
| | - Jordan C. Weyer
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer L. Wheeler
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sidney W. Whiteheart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, United States of America
| | - Zanthia Wiley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Natasha J. Williams
- Institute for Excellence in Health Equity, NYU Grossman School of Medicine, New York, New York, United States of America
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - John C. Wood
- Department of Pediatrics and Radiology, Children’s Hospital of Los Angeles, Los Angeles, California, United States of America
| | - Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Natalie M. Young
- Swedish Center for Research and Innovation, Providence Swedish Medical Center, Seattle, Washington, United States of America
| | - Sokratis N. Zisis
- Department of Medicine, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Andrea S. Foulkes
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Alabi O, Hunt KJ, Patzer RE, Henry Akintobi T, Massarweh NN. Racial Differences in Vascular Assessment Prior to Amputation in the Veterans Health Administration. Health Equity 2023; 7:346-350. [PMID: 37284536 PMCID: PMC10240309 DOI: 10.1089/heq.2023.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 06/08/2023] Open
Abstract
Purpose It is unclear whether disparities in the care provided before lower extremity amputation (LEA) is driven by differences in receipt of diagnostic work-up versus revascularization attempts. Methods We performed a national cohort study of Veterans who underwent LEA between March 2010 and February 2020 to assess receipt of vascular assessment with arterial imaging and/or revascularization in the year prior to LEA. Results Among 19,396 veterans (mean age 66.8 years; 26.6% Black), Black veterans had diagnostic procedures more often than White veterans (47.5% vs. 44.5%) and revascularization as often (25.8% vs. 24.5%). Conclusion We must identify patient and facility-level factors associated with LEA as disparities do not appear related to differences in attempted revascularization.
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Affiliation(s)
- Olamide Alabi
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rachel E. Patzer
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tabia Henry Akintobi
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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Ross-Driscoll K, Harding JL, Labgold K, Gunasti J, Lynch RJ, Patzer RE. The Impact of Selection Bias in Transplant Research Intended to Inform Patient Selection: An Example and Potential Solutions. Transplantation 2023; 107:805-807. [PMID: 36584372 PMCID: PMC10122512 DOI: 10.1097/tp.0000000000004463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Katie Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA
| | - Jessica L. Harding
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA
| | - Katie Labgold
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jonathan Gunasti
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Raymond J. Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Snyder JJ, Schaffhausen CR, Hart A, Axelrod DA, Dils D, Formica RN, Gaber AO, Hunt HF, Jones J, Mohan S, Patzer RE, Pinney SP, Ratner LE, Slaker D, Stewart D, Stewart ZA, Van Slyck S, Kasiske BL, Hirose R, Israni AK. Stakeholders' Perspectives on Transplant Metrics: The 2022 Scientific Registry of Transplant Recipients' Consensus Conference. Am J Transplant 2023:S1600-6135(23)00355-6. [PMID: 36958628 DOI: 10.1016/j.ajt.2023.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023]
Abstract
In July 2022, the Scientific Registry of Transplant Recipients (SRTR) hosted an innovative, multistakeholder consensus conference to identify information and metrics desired by stakeholders in the transplantation system, including patients, living donors, caregivers, deceased donor family members, transplant professionals, organ procurement organization professionals, payers, and regulators. Crucially, patients, caregivers, living donors, and deceased donor family members were included in all aspects of this conference, including serving on the planning committee, participating in preconference focus groups and learning sessions, speaking at the conference, moderating conference sessions and breakout groups, and shaping the conclusions. Patients constituted 24% of the meeting participants. In this report, we document the proceedings and enumerate 160 recommendations, 10 of which have been highly prioritized. SRTR will use the recommendations to develop new presentations of information and metrics requested by stakeholders to support informed decision-making.
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Affiliation(s)
- Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; University of Iowa Transplant Institute, Iowa City, Iowa, USA
| | - Dorrie Dils
- Gift of Life Michigan, Ann Arbor, Michigan, USA
| | | | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, J.C. Walter Jr. Transplant Center, Houston, Texas, USA
| | | | - Jennifer Jones
- American Association of Kidney Patients, Kidney Transplant Recipient
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sean P Pinney
- Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University, New York, New York
| | - Dirk Slaker
- Optum Health Solutions, Eden Prairie, Minnesota, USA
| | - Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Zoe A Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | | | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Arenson M, Hogan J, Xu L, Lynch R, Lee YTH, Choi JD, Sun J, Adams A, Patzer RE. Predicting Kidney Transplant Recipient Cohorts' 30-Day Rehospitalization Using Clinical Notes and Electronic Health Care Record Data. Kidney Int Rep 2023; 8:489-498. [PMID: 36938078 PMCID: PMC10014371 DOI: 10.1016/j.ekir.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Rehospitalization after kidney transplant is costly to patients and health care systems and is associated with poor outcomes. Few prediction model studies have examined whether inclusion of clinical notes data from the electronic medical record (EMR) enhances prediction of rehospitalization. Methods In a retrospective, observational study of first-time, adult kidney transplant recipients at a large, urban hospital in southeastern United States (2005-2015), we examined 30-day rehospitalization (30DR) using structured EMR and unstructured (i.e., clinical notes) data. We used natural language processing (NLP) methods on 8 types of clinical notes and included terms in predictive models using unsupervised machine learning approaches. Both the area under the receiver operating curve and precision-recall curve (ROC and PRC, respectively) were used to determine and compare model accuracy, and 5-fold cross-validation tested model performance. Results Among 2060 kidney transplant recipients, 30.7% were readmitted within 30 days. Predictive models using clinical notes did not meaningfully improve performance over previous models using structured data alone (ROC 0.6821; 95% confidence interval [CI]: 0.6644, 0.6998). Predictive models built using solely clinical notes performed worse than models using both clinical notes and structured data. The data that contributed to the top performing models were not identical but both included structured data and progress notes (ROC 0.6902; 95% CI: 0.6699, 0.7105). Conclusions Including new features from clinical notes in risk prediction models did not substantially increase predictive accuracy for 30DR for kidney transplant recipients. Future research should consider pooling data from multiple institutions to increase sample size and avoid overfitting models.
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Affiliation(s)
- Michael Arenson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Pediatrics, Child Health Equity Center, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Julien Hogan
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Liyan Xu
- Department of Computer Science, Emory University, Atlanta, Georgia, USA
| | - Raymond Lynch
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yi-Ting Hana Lee
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jinho D. Choi
- Department of Computer Science, Emory University, Atlanta, Georgia, USA
| | - Jimeng Sun
- Department of Computer Science, University of Illinois, Urbana-Champaign, Champaign, Illinois, USA
| | - Andrew Adams
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health Emory University, Atlanta, Georgia, USA
- Correspondence: Rachel E. Patzer, Department of Surgery, Emory University School of Medicine, 101 Woodruff Circle, 5101 WMB, Atlanta, Georgia 30322, USA.
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King KL, Yu M, Husain SA, Patzer RE, Sandra V, Reese PP, Schold JD, Mohan S. Contribution of Estimates of Glomerular Filtration to the Extensive Disparities in Preemptive Listing for Kidney Transplant. Kidney Int Rep 2023; 8:442-454. [PMID: 36938099 PMCID: PMC10014377 DOI: 10.1016/j.ekir.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction The use of race coefficients in equations for estimated glomerular filtration rate (eGFR) may have contributed to racial disparities in access to preemptive (without dialysis exposure) kidney transplantation (Ktx). Methods In this retrospective national cohort study of incident kidney transplant candidates in the United States from 2001 to 2019, we describe temporal trends and racial disparities in preemptive listing and the distribution of eGFR at listing, using eGFR as reported and after removing the race coefficient for Black candidates. Results Among 511,686 candidates, preemptive listing increased over time, from 18% in 2001 to 33% in 2019. Non-Black candidates were listed preemptively nearly twice as frequently as Black candidates in 2019 (38% vs. 21% preemptive) and at higher eGFR values (median 15.6 vs. 15.0 ml/min per 1.73 m2). After adjusting for candidate characteristics, including listing eGFR without the race coefficient, preemptive Black candidates still had significantly lower odds of preemptive deceased donor (DD) kidney transplantation compared to non-Black candidates (odds ratio 0.87, 95% confidence interval: 0.78-0.98). Conclusions Over the last 2 decades, Black patients were consistently less likely to be listed preemptively and were listed at lower eGFR values. Adjusting for listing eGFR with the race coefficient computationally removed did not eliminate the racial disparity, suggesting that additional efforts are needed to achieve equity in preemptive transplantation beyond adopting race-free eGFR equations.
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Affiliation(s)
- Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vanessa Sandra
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Correspondence: Sumit Mohan, Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, Ph4-124, New York, New York 10032, USA.
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Patzer RE, Zhang R, Buford J, McPherson L, Lee YTH, Urbanski M, Li D, Wilk A, Paul S, Plantinga L, Escoffery C, Pastan SO. The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial. Clin J Am Soc Nephrol 2023; 18:374-382. [PMID: 36764664 PMCID: PMC10103253 DOI: 10.2215/cjn.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting. METHODS The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients. RESULTS Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42). CONCLUSIONS The ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER National Institutes of Health ( NCT02879812 ). PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_03_08_CJN09760822.mp3.
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Affiliation(s)
- Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rebecca Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jade Buford
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-Ting Hana Lee
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Megan Urbanski
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Dong Li
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cam Escoffery
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Hart A, Patzer RE, Spear J, Hirose R, Tabatabai A, Wood NL, Schaffhausen CR, Axelrod DA, Israni AK, Snyder JJ. Time to discard the term "discard". Am J Transplant 2023; 23:608-610. [PMID: 36740191 DOI: 10.1016/j.ajt.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/10/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
The 2022 Scientific Registry of Transplant Recipients Consensus Conference "People Driven Transplant Metrics" offered an opportunity for a diverse group of stakeholders in the solid organ transplant community to exchange ideas about what information and metrics are important to different stakeholders. Participating patients and family members called on the transplant community to cease using the term "discards" to refer to donated organs that are not transplanted.
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Affiliation(s)
- Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Spear
- Deceased Donor Family Member, Region 8 Representative, Patient Affairs Committee, Organ Procurement and Transplantation Network, Boulder, CO, USA
| | - Ryutaro Hirose
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ameen Tabatabai
- Patient representative, Patient and Family Advisory Subcommittee, Scientific Registry of Transplant Recipients, Los Angeles, CA, USA
| | - Nicholas L Wood
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Cory R Schaffhausen
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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Trandel ET, Lowers J, Bannon ME, Moreines LT, Dellon EP, White P, Cross SH, Quest TE, Lagnese K, Krishnamurti T, Arnold RM, Harrison KL, Patzer RE, Wang L, Zarrabi AJ, Kavalieratos D. Barriers of Acceptance to Hospice Care: a Randomized Vignette-Based Experiment. J Gen Intern Med 2023; 38:277-284. [PMID: 35319086 PMCID: PMC9905383 DOI: 10.1007/s11606-022-07468-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The per diem financial structure of hospice care may lead agencies to consider patient-level factors when weighing admissions. OBJECTIVE To investigate if treatment cost, disease complexity, and diagnosis are associated with hospice willingness to accept patients. DESIGN In this 2019 online survey study, individuals involved in hospice admissions decisions were randomized to view one of six hypothetical patient vignettes: "high-cost, high-complexity," "low-cost, high-complexity," and "low-cost, low-complexity" within two diseases: heart failure and cystic fibrosis. Vignettes included demographics, prognoses, goals, and medications with costs. Respondents indicated their perceived likelihood of acceptance to their hospice; if likelihood was <100%, respondents were asked the barriers to acceptance. We used bivariate tests to examine associations between demographic, clinical, and organizational factors and likelihood of acceptance. PARTICIPANTS Individuals involved in hospice admissions decisions MAIN MEASURES: Likelihood of acceptance to hospice care KEY RESULTS: N=495 (76% female, 53% age 45-64). Likelihoods of acceptance in cystic fibrosis were 79.8% (high-cost, high-complexity), 92.4% (low-cost, high-complexity), and 91.5% (low-cost, low-complexity), and in heart failure were 65.9% (high-cost, high-complexity), 87.3% (low-cost, high-complexity), and 96.6% (low-cost, low-complexity). For both heart failure and cystic fibrosis, respondents were less likely to accept the high-cost, high-complexity patient than the low-cost, high-complexity patient (65.9% vs. 87.3%, 79.8% vs. 92.4%, both p<0.001). For heart failure, respondents were less likely to accept the low-cost, high-complexity patient than the low-cost, low-complexity patient (87.3% vs. 96.6%, p=0.004). Treatment cost was the most common barrier for 5 of 6 vignettes. CONCLUSIONS This study suggests that patients receiving expensive and/or complex treatments for palliation may have difficulty accessing hospice.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Li Wang
- University of Pittsburgh, Pittsburgh, USA
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Orenstein LAV, Salame N, Siira MR, Urbanski M, Flowers NI, Echuri H, Garg A, McKenzie-Brown AM, Curseen KA, Patzer RE, Kavalieratos D, Chen SC. Pain experiences among those living with hidradenitis suppurativa: a qualitative study. Br J Dermatol 2023; 188:41-51. [PMID: 36689519 DOI: 10.1093/bjd/ljac018] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/21/2022] [Accepted: 09/24/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pain is rated by patients with hidradenitis suppurativa (HS) as the disease's most impactful symptom. HS therapies are often insufficient to control inflammatory disease activity and pain. A better understanding of patient experiences with pain may improve patient-provider relationships and help identify strategies for addressing HS pain. OBJECTIVES This qualitative study sought to characterize lived pain experiences of those with HS. METHODS English-speaking patients ≥ 18 years old with a dermatologist-confirmed diagnosis of HS and an average numerical rating scale pain score of ≥ 1 over the preceding week were recruited from a single academic medical centre in Atlanta, Georgia, USA. Semistructured interviews were conducted from November 2019 to March 2020 to explore participants' HS pain experiences and the subsequent impact on their lives. Thematic saturation was reached after interviewing 21 participants. Interviews were audio recorded, transcribed, and analysed using thematic analysis. RESULTS Among 21 study participants, the median 7-day average pain score was 6 (interquartile range 3-7; scale ranges from 0 to 10, with 10 being most pain). Participants' descriptions of pain were consistent with nociceptive pain, neuropathic pain and itch. Pain impacted multiple life domains, including physical limitations (decreased mobility and impaired sleep), decreased psychological wellbeing (irritability, depression, loss of control, and difficulty communicating pain experiences) and impaired social relationships (social isolation, intimacy problems and difficulty fulfilling social responsibilities). Although participants reported chronic discomfort, acutely painful and unpredictable HS disease flares caused more distress and quality-of-life (QoL) burden. Participants frequently treated their pain without input from the medical team, sometimes with unsafe medication doses or combinations. Factors contributing to self-management of pain included difficulty accessing timely outpatient care during disease flares and fear of stigma from healthcare providers. CONCLUSIONS When present, HS-related pain may impact not only physical wellbeing but also mental health and relationships. In addition to therapies that target the inflammatory disease burden, treating the symptom of pain may improve patients' QoL and wellbeing. Because patients with HS have difficulty explaining their pain, proactively asking them about pain may identify unmet needs, facilitate better pain control and improve QoL. Further, the influence of HS-related pain on numerous aspects of QoL suggests the need for multidisciplinary, patient-centred approaches to HS pain management.
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Affiliation(s)
- Lauren A V Orenstein
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicole Salame
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Meron R Siira
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Megan Urbanski
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA, USA
| | - Nyla I Flowers
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Harika Echuri
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | | | - Kimberly A Curseen
- Department of Family and Preventive Medicine, Division of Palliative Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA, USA
| | - Dio Kavalieratos
- Department of Family and Preventive Medicine, Division of Palliative Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Suephy C Chen
- Department of Dermatology, Duke University School of Medicine, Durham, NC, USA
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Harding JL, Oviedo SA, Ali MK, Ofotokun I, Gander JC, Patel SA, Magliano DJ, Patzer RE. The bidirectional association between diabetes and long-COVID-19 - A systematic review. Diabetes Res Clin Pract 2023; 195:110202. [PMID: 36496030 PMCID: PMC9727969 DOI: 10.1016/j.diabres.2022.110202] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/15/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Some evidence suggests that diabetes may be a risk factor for the development of post-acute sequelae of COVID-19 (PASC). Recent data also indicate that new-onset diabetes may be a complication of COVID-19. Here, we review the existing evidence. Following PRISMA guidelines, we conducted a systematic review through August 8, 2022. We included longitudinal studies reporting on the risk of PASC (i.e., sequelae that extend beyond four weeks after initial infection) in people with and without diabetes, and studies reporting on the risk of new-onset diabetes in people with vs without COVID-19 with a minimum of 4-weeks of follow-up. All studies were published in English. Among 5,532 studies screened, 39 were included in the final review. Among 25 studies reporting on diabetes and PASC, 44 % (n = 11) identified diabetes as a significant risk factor for PASC (increased relative risk ranging from 7 % to 342 %) while 56 % (n = 14) did not. Among 14 studies reporting on new-onset diabetes, 12 (86 %) reported that COVID-19 (vs no COVID) was significantly associated with new-onset diabetes with increased risks ranging from 11 % to 276 %. COVID-19 survivors may be at increased risk for new-onset diabetes, but whether pre-existing diabetes is also a risk factor for PASC remains unclear.
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Affiliation(s)
- Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.
| | - Sofia A Oviedo
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, United States
| | - Igho Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States; Department of Behavioral Science and Education, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Grady Healthcare System Infection Disease Program, Atlanta, GA, United States
| | - Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States
| | - Shivani A Patel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Dianna J Magliano
- Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States; Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
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Patzer RE, Di M, Zhang R, McPherson L, DuBay DA, Ellis M, Wolf J, Jones H, Zayas C, Mulloy L, Reeves-Daniel A, Mohan S, Perez AC, Trivedi AN, Pastan SO. Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System. Am J Kidney Dis 2022; 80:707-717. [PMID: 35301050 PMCID: PMC9470777 DOI: 10.1053/j.ajkd.2022.01.423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 01/03/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS 37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012. EXPOSURE KAS era (pre-KAS vs post-KAS). OUTCOME Referral for transplantation, start of transplant evaluation, and waitlisting. ANALYTICAL APPROACH Multivariable time-dependent Cox models for the incident and prevalent population. RESULTS Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred. LIMITATIONS Limited to 3 states, residual confounding. CONCLUSIONS In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Mengyu Di
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Derek A DuBay
- Medical University of South Carolina, Charleston, South Carolina
| | - Matthew Ellis
- Department of Medicine and Department of Surgery, Duke University, Durham, North Carolina
| | - Joshua Wolf
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | | | - Carlos Zayas
- Medical University of South Carolina, Charleston, South Carolina
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia
| | | | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York
| | - Aubriana C Perez
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Amal N Trivedi
- Brown University School of Public Health, Providence, Rhode Island; Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, Rhode Island
| | - Stephen O Pastan
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
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Crews DC, Patzer RE, Cervantes L, Knight R, Purnell TS, Powe NR, Edwards DP, Norris KC. Designing Interventions Addressing Structural Racism to Reduce Kidney Health Disparities: A Report from a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. J Am Soc Nephrol 2022; 33:2141-2152. [PMID: 36261301 PMCID: PMC9731627 DOI: 10.1681/asn.2022080890] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Structural racism embodies the many ways in which society fosters racial discrimination through "mutually reinforcing inequitable systems" that limit access to resources and opportunities that can promote health and well being among marginalized communities. To achieve health equity, and kidney health equity more specifically, structural racism must be eliminated. In February 2022, the National Institute of Diabetes and Digestive and Kidney Diseases convened the "Designing Interventions that Address Structural Racism to Reduce Kidney Health Disparities" workshop, which was aimed at describing the mechanisms through which structural racism contributes to health and health care disparities for people along the continuum of kidney disease and identifying actionable opportunities for interventional research focused on dismantling or addressing the effects of structural racism. Participants identified six domains as key targets for interventions and future research: (1) apply an antiracism lens, (2) promote structural interventions, (3) target multiple levels, (4) promote effective community and stakeholder engagement, (5) improve data collection, and (6) advance health equity through new health care models. There is an urgent need for research to develop, implement, and evaluate interventions that address the unjust systems, policies, and laws that generate and perpetuate inequities in kidney health.
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Affiliation(s)
- Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health and School of Medicine, Emory University, Atlanta, Georgia
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Lilia Cervantes
- Division of Hospital Medicine and General Internal Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Richard Knight
- American Association of Kidney Patients, Tampa, Florida
- College of Business, Bowie State University, Bowie, Maryland
| | - Tanjala S. Purnell
- Departments of Epidemiology and Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Neil R. Powe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | | | - Keith C. Norris
- Department of Medicine, University of California Los Angeles, Los Angeles, California
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40
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Dixon SN, Naylor KL, Yohanna S, McKenzie S, Belenko D, Blake PG, Coghlan C, Cooper R, Elliott L, Getchell L, Ki V, Mucsi I, Nesrallah G, Patzer RE, Presseau J, Reich M, Sontrop JM, Treleaven D, Waterman AD, Zaltzman J, Garg AX. Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD): Statistical Analysis Plan of a Registry-Based, Cluster-Randomized Clinical Trial. Can J Kidney Health Dis 2022; 9:20543581221131201. [PMID: 36438439 PMCID: PMC9693773 DOI: 10.1177/20543581221131201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) is a quality improvement intervention designed to enhance access to kidney transplantation and living kidney donation. We conducted a cluster-randomized clinical trial to evaluate the effect of the intervention versus usual care on completing key steps toward receiving a kidney transplant. OBJECTIVE To prespecify the statistical analysis plan for the EnAKT LKD trial. DESIGN The EnAKT LKD trial is a pragmatic, 2-arm, parallel-group, registry-based, open-label, cluster-randomized, superiority, clinical trial. Randomization was performed at the level of the chronic kidney disease (CKD) programs (the "clusters"). SETTING Twenty-six CKD programs in Ontario, Canada. PARTICIPANTS More than 10 000 patients with advanced CKD (ie, patients approaching the need for dialysis or receiving maintenance dialysis) with no recorded contraindication to receiving a kidney transplant. METHODS The trial data (including patient characteristics and outcomes) will be obtained from linked administrative health care databases (the "registry"). Stratified covariate-constrained randomization was used to allocate the 26 CKD programs (1:1) to provide the intervention or usual care from November 1, 2017, to December 31, 2021 (4.17 years). CKD programs in the intervention arm received the following: (1) support for local quality improvement teams and administrative needs; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders. OUTCOMES The primary outcome is completing key steps toward receiving a kidney transplant, where up to 4 unique steps per patient will be considered: (1) patient referred to a transplant center for evaluation, (2) a potential living kidney donor begins their evaluation at a transplant center to donate a kidney to the patient, (3) patient added to the deceased donor transplant waitlist, and (4) patient receives a kidney transplant from a living or deceased donor. ANALYSIS PLAN Using an intent-to-treat approach, the primary outcome will be analyzed using a patient-level constrained multistate model adjusting for the clustering in CKD programs. TRIAL STATUS The EnAKT LKD trial period is November 1, 2017, to December 31, 2021. We expect to analyze and report the results once the data for the trial period is available in linked administrative health care databases. TRIAL REGISTRATION The EnAKT LKD trial is registered with the U.S. National Institute of Health at clincaltrials.gov (NCT03329521 available at https://clinicaltrials.gov/ct2/show/NCT03329521). STATISTICAL ANALYTIC PLAN Version 1.0 August 26, 2022.
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Affiliation(s)
- Stephanie N. Dixon
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- ICES, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Kyla L. Naylor
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- ICES, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | | | - Dmitri Belenko
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Peter G Blake
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Candice Coghlan
- Centre for Living Organ Donation, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Leah Getchell
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- Can-SOLVE CKD Network, Vancouver, British Columbia, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Istvan Mucsi
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Ajmera Transplant Center, University Health Network, Toronto, Ontario, Canada
| | - Gihad Nesrallah
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Rachel E. Patzer
- Health Services Research Center, Emory University School of Medicine, Atlanta, Ontario, USA
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Patient Council, Vancouver, British Columbia, Canada
| | - Jessica M. Sontrop
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Darin Treleaven
- McMaster University, Hamilton, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
| | - Amy D. Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, TX, USA
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Amit X. Garg
- Lawson Health Research Institute, London, Ontario, Canada
- ICES, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
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Ross-Driscoll K, Gunasti J, Lynch RJ, Massie A, Segev DL, Snyder J, Axelrod D, Patzer RE. Response to "non-local kidney transplantation and transplant outcomes". Am J Transplant 2022; 22:2487-2488. [PMID: 35587191 DOI: 10.1111/ajt.17099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Katherine Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan Gunasti
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Raymond J Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Allan Massie
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David Axelrod
- Department of Surgery, Solid Organ Transplant Center, University of Iowa, Iowa City, IA, USA
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Patzer RE, Adler JT, Harding JL, Huml A, Kim I, Ladin K, Martins PN, Mohan S, Ross-Driscoll K, Pastan SO. A Population Health Approach to Transplant Access: Challenging the Status Quo. Am J Kidney Dis 2022; 80:406-415. [PMID: 35227824 DOI: 10.1053/j.ajkd.2022.01.422] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/09/2022] [Indexed: 01/27/2023]
Abstract
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Joel T Adler
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts; Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anne Huml
- Case Center for Reducing Health Disparities, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts; Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University, New York, New York
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Wilk AS, Drewry KM, Zhang R, Pastan SO, Thorsness R, Trivedi AN, Patzer RE. Treatment Patterns and Characteristics of Dialysis Facilities Randomly Assigned to the Medicare End-Stage Renal Disease Treatment Choices Model. JAMA Netw Open 2022; 5:e2225516. [PMID: 35930284 PMCID: PMC9356315 DOI: 10.1001/jamanetworkopen.2022.25516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE In 2021, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) model, which randomly assigned approximately 30% of dialysis facilities to new financial incentives to increase use of transplantation and home dialysis; these financial bonuses and penalties are calculated by comparing living-donor transplantation, transplant wait-listing, and home dialysis use in ETC-assigned facilities vs benchmarks from non-ETC-assigned (ie, control) facilities. Because model participation is randomly assigned, evaluators may attribute any downstream differences in outcomes to facility performance rather than any imbalance in baseline characteristics. OBJECTIVE To identify preintervention imbalances in dialysis facility characteristics that should be recognized in any ETC model evaluations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared ETC-assigned and control dialysis facility characteristics in the United States from 2017 to 2018. A total of 6062 facilities were included. Data were analyzed from February 2021 to May 2022. EXPOSURES Assignment to the ETC model. MAIN OUTCOMES AND MEASURES Dialysis facilities' preintervention transplantations and home dialysis use, facility characteristics (notably, profit and chain status), patient demographic characteristics, and community socioeconomic characteristics. RESULTS Among 316 927 patients, with 6 178 855 attributed patient-months, the mean (SD) age in January 2017 was 59 (11) years, and 132 462 (42%) were female. Patients in ETC-assigned facilities had 9% (0.2 [95% CI, 0.1-0.2] percentage points) lower prevalence of living donor transplantation, 12% (3.2 [95% CI, 3.0-3.3] percentage points) lower prevalence of transplantation wait-listing, and 4% (0.4 [95% CI, 0.3-0.4] percentage points) lower prevalence of peritoneal dialysis use compared with control facilities. ETC-assigned facilities were 14% (5.1 [95% CI, 0.9-9.4] percentage points) more likely than control facilities to be owned by the second largest dialysis organization. Relative to control facilities, ETC-assigned facilities also treated 34% (6.6 [95% CI, 6.5-6.7] percentage point) fewer patients with Hispanic ethnicity and were located in communities with median household incomes that were 4% ($2500; 95% CI, $500-$4500) lower on average. CONCLUSIONS AND RELEVANCE In this study, dialysis facilities in ETC-assigned regions had lower preintervention prevalence of transplantation wait-listing, living donor transplantation, and peritoneal dialysis use, relative to control facilities. ETC-assigned and control facilities also differed with respect to other facility, patient, and community characteristics. Evaluators should account for these preintervention imbalances to minimize bias in their inferences about the model's association with postintervention outcomes.
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Affiliation(s)
- Adam S. Wilk
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kelsey M. Drewry
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Zhang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
| | - Rebecca Thorsness
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Amal N. Trivedi
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Rachel E. Patzer
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
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Ross-Driscoll K, Gunasti J, Lynch RJ, Massie A, Segev DL, Snyder J, Axelrod D, Patzer RE. Listing at non-local transplant centers is associated with increased access to deceased donor kidney transplantation. Am J Transplant 2022; 22:1813-1822. [PMID: 35338697 PMCID: PMC9580509 DOI: 10.1111/ajt.17044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 01/25/2023]
Abstract
The ability of kidney transplant candidates to travel outside of their usual place of care varies by sociodemographic factors, potentially exacerbating disparities in access. We used Transplant Referral Regions (TRRs) to overcome previous methodological barriers of using geographic distance to assess the characteristics and outcomes of patients listed for kidney transplant at centers in neighboring TRR or beyond neighboring TRRs. Among listed kidney transplant candidates, 20.9% traveled to a neighbor and 5.6% beyond a neighbor. A higher proportion of travelers were White, had some college education, and lived in ZIP codes with lower poverty. Travel to a neighbor was associated with a 7% increase in likelihood of deceased donor transplant (cHR: 1.07, 95% CI: 1.05, 1.09) and traveling beyond a neighbor with a 19% increase (cHR: 1.19, 95% CI: 1.15, 1.24). Travelers had similar rates of living donor transplant and waitlist mortality as patients who did not travel; those who traveled beyond a neighbor had slightly lower posttransplant mortality (HR: 0.91, 95% CI: 0.83, 0.99). In conclusion, the ability to travel outside of the recipient's assigned TRR increases access to transplantation and improves long-term survival.
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Affiliation(s)
- Katherine Ross-Driscoll
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan Gunasti
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia,Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raymond J. Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Massie
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jon Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota,Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David Axelrod
- Solid Organ Transplant Center, Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Urbanski MA, Patzer RE. Measuring Disease and Transplant Knowledge among Patients with Advanced CKD: Tools to Increase Access and Advance Equity. Clin J Am Soc Nephrol 2022; 17:481-483. [PMID: 35332060 PMCID: PMC8993482 DOI: 10.2215/cjn.02140222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Megan A. Urbanski
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Department of Medicine, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Department of Medicine, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Snow KK, Patzer RE, Patel SA, Harding JL. County-Level Characteristics Associated with Variation in ESKD Mortality in the United States, 2010-2018. Kidney360 2022; 3:891-899. [PMID: 36128479 PMCID: PMC9438422 DOI: 10.34067/kid.0007872021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/25/2022] [Indexed: 01/10/2023]
Abstract
Background Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. Methods We identified 1,515,986 individuals (aged 18-84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. Results County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (-4.94 per 1000 PY), lower transplant rate (-4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality. Conclusions Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.
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Affiliation(s)
- Kylie K. Snow
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Shivani A. Patel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Adler RR, Smith RN, Fowler KJ, Gates J, Jefferson NM, Adler JT, Patzer RE. Community Based Participatory Research (CBPR): An Underutilized Approach to Address Surgical Disparities. Ann Surg 2022; 275:496-499. [PMID: 34913903 DOI: 10.1097/sla.0000000000005329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.
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Affiliation(s)
- Rachel R Adler
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
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48
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Wilk AS, Cummings JR, Plantinga LC, Franch HA, Lea JP, Patzer RE. Racial and Ethnic Disparities in Kidney Replacement Therapies Among Adults With Kidney Failure: An Observational Study of Variation by Patient Age. American Journal of Kidney Diseases 2022; 80:9-19. [DOI: 10.1053/j.ajkd.2021.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022]
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Adekunle RO, Zhang R, Wang Z, Patzer RE, Mehta AK. Early steps to kidney transplantation among persons with HIV and end-stage renal disease in ESRD network 6. Transpl Infect Dis 2022; 24:e13767. [PMID: 34813136 PMCID: PMC8825692 DOI: 10.1111/tid.13767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION End-stage renal disease is a significant cause of morbidity and mortality in persons with HIV (PWH). Limited data exist on access to kidney transplantation for this population. METHODS A dataset inclusive of incident dialysis patients between 2012 and 2016 with follow-up through December 2017 that identifies PWH and the general dialysis population of Network 6 (Georgia, North Carolina, South Carolina) was created through merging the United States Renal Data System with the southeastern early transplant access registry. Early steps to kidney transplantation and patient and dialysis facility-level characteristics that serve as barriers to transplantation were described. RESULTS Twenty-three thousand four hundred fourteen patients were identified; 469 were PWH. Compared to non-HIV individuals, PWH were younger (49 vs. 58 years, p < 0.001), predominantly Black (87% vs. 56% p < 0.001) and male (72% vs. 56% p < 0.001). PWH were less likely to be referred to kidney transplant within 1 year of starting dialysis (36% vs. 41% p < 0.001) and waitlisted within 1 year of evaluation-start (14% vs. 30%, p = 0.05). PWH (vs. non-PWH) waited longer for referral, evaluation-start, and waitlisting and in multivariable analysis; HIV positivity was associated with a lower probability of referral (hazard ratios [HR]: 0.70; 95% confidence intervals [CIs]: 0.62-0.80), evaluation (HR 0.66; 95% CI: 0.55-0.80), and waitlisting (HR 0.29; 95% CI: 0.20-0.41). CONCLUSIONS Targeted interventions are needed to improve access to kidney transplants, particularly in waitlisting, for PWH.
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Affiliation(s)
- Ruth O Adekunle
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Rebecca Zhang
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zhengsheng Wang
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E Patzer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Aneesh K Mehta
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia Emory Transplant Center, Atlanta, Georgia,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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50
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Perez A, Retzloff S, Browne T, Cruz A, Wright S, Pastan SO, Patzer RE. Dialysis staff-reported impact of COVID-19 on early kidney transplant steps. Kidney Int Rep 2022; 7:904-907. [PMID: 35018309 PMCID: PMC8739365 DOI: 10.1016/j.ekir.2022.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/13/2021] [Accepted: 01/03/2022] [Indexed: 12/21/2022] Open
Affiliation(s)
- Aubriana Perez
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Samantha Retzloff
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Teri Browne
- College of Social Work, University of South Carolina, Columbia, South Carolina, USA
| | - Alexandra Cruz
- IPRO ESRD Network of the South Atlantic, Morrisville, North Carolina, USA
| | - Shannon Wright
- IPRO ESRD Network of the South Atlantic, Morrisville, North Carolina, USA
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Correspondence: Rachel E. Patzer, Division of Transplantation, Department of Surgery, Emory University School of Medicine, 101 Woodruff Circle, 5101 WMB, Atlanta, Georgia 30322, USA.
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